Nathan D Wong PhD Professor and Director Heart Disease Prevention Program Division of Cardiology University of California Irvine Dietary Effects on Lipids Seven Countries study showed significant correlation between saturated fat intake and blood cholesterol levels ID: 465905
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Slide1
Nutrition and Cardiovascular Disease: Evidence and Guidelines
Nathan D. Wong, PhD
Professor and Director
Heart Disease Prevention Program
Division of Cardiology, University of California, IrvineSlide2
Dietary Effects on Lipids
Seven Countries study showed significant correlation between saturated fat intake and blood cholesterol levels
Meta-analysis of randomized controlled trials shows lowering saturated fat and cholesterol to reduce total and LDL-C 10-15%
For every 1% increase in intake of saturated fat, blood cholesterol increases 2 mg/dl
Soluble fiber intake may provide additional LDL-C response over that of a low-fat dietSlide3
Dietary Effects on Thrombosis
Omega-3 fatty acids have antithrombogenic and antiarrhythmic effects, decreased platelet aggregation, and lower triglycerides
Eskimos’ cold water fish diet associated with prolonged bleeding times and lower rates of MI; similar findings in Japan, Netherlands, and England
Lyon Diet-Heart Study reported increased survival following Mediterranean diet with fish and high in linolenic acid (no lipid differences seen).Slide4
Associations between the percent of calories derived from specific foods and CHD mortality in the 20 Countries Study*
Butter 0.546
All dairy products 0.619
Eggs 0.592
Meat and poultry 0.561
Sugar and syrup 0.676
Grains, fruits, and starchy -0.633
and nonstarchy vegetables
Food Source Correlation Coefficient†
*1973 data, all subjects. From Stamler J: Population studies. In Levy R: Nutrition, Lipids, and CHD. New York, Raven, 1979. †All coefficients are significant at the P<0.05 level.Slide5
Men participating in the Ni-Hon-San study*
Age (years) 57 54 52
Weight (kg) 55 63 66
Serum cholesterol (mg/dL) 181 218 228
Dietary fat (% of calories) 15 33 38
Dietary protein (%) 14 17 16
Dietary carbohydrate (%) 63 46 44
Alcohol (%) 9 4 3
5-yr CHD mortality rate 1.3 2.2 3.7
(per 1,000)
Residence
Japan Hawaii California
*Data from Kato et al.
Am J Epidemiol
1973;97:372. CHD, coronary heart disease.Slide6
Epidemiologic studies*
Populations on diets high in total fat, saturated fat, cholesterol, and sugar have high age-adjusted CHD death rates as well as more obesity, hypercholesterolaemia, and diabetes
The converse is also true
What is the evidence for dietary intervention studies?
*Results from Seven Countries, 18 countries, 20 countries, 40 countries,
and Ni-Hon-San StudiesSlide7
Oslo Diet Heart Study
412 men with CHD, 5 year study
Treatment group randomized to low saturated fat (8.4% of calories), low cholesterol (264 mg/day), high polyunsaturated fat (15.5%) diet
Serum cholesterol reduced 14%
33% reduction in MI, 26% decrease in CHD mortality
Dietary counseling every 3 months
Leren et al.
Acta Med. Scand 1966; 466:1.Slide8
Los Angeles VA study
846 men in Veterans Home, 5-8 years
Groups randomized to diets in which 2/3 of fat given either as vegetable oil (corn, cottonseed, safflower, soybean) or animal fat
Saturated fat 11% vs. 18%, polyunsaturated fat 16% vs. 5% of calories
31% decrease in CVD endpoints
Dayton et al.
Circulation
1969; 40:1.Slide9
Lyon Diet Heart study
302 men and women with CHD
Treatment group randomized to low saturated fat, high canola oil margarine (5% alpha linolenic, 16% linoleic, and 48% oleic acid, also 5%
trans
)
46 month follow-up
65% lower CHD death rate in treatment group (6 vs. 19 death)
de Lorgeril et al. Circulation 1999; 99:779-785.Slide10
Stanford Coronary Risk
Intervention Project (SCRIP)
300 men and woman with CHD, baseline and 4 year follow-up angiograms
Randomized to <20% fat, <6% saturated fat, <75 mg cholesterol/day, and exercise (Rx group) vs usual care
LDL-C and TG decreased 22% and 20%, and HDL-C increased 20%
Rx group had 47% less progression than control group,
P
<0.02
Haskell et al.
Circulation 1994; 89:975-990. Quinn et al. JACC 1994; 24:900-908.Slide11
U.S. Diabetes Prevention Project
3234 subjects with BMI > 34 kg/m
2
Placebo, metformin, and lifestyle modification
Lifestyle modification goal > 7% weight loss with diet and exercise (
150 min / week)
New onset diabetes: 11% placebo,
7% metformin, 4.8% lifestyle groupNEJM 2002Slide12
Finnish Diabetes Prevention Study
522 overweight subjects; Intervention group - met with dietician 4 x /yr and supervised exercise vs control group (pamphlet)
Goals: 1) 5 lb wt loss 2) 15gm of fiber/1000 cal 3) < 30% fat 4) < 10% saturated fat 5) 30 minutes of exercise /day
Intervention group met 4/5 goals 0% new diabetes, vs control group met 0 goals 32% new diabetes
NEJM 2001Slide13
Benefits of fish oil supplementation
In the Diet and Reinfarction Trial (DART) in 2033 men with CHD increased intake of fish or use of 2 fish oil caps/day reduced CHD mortality 29% over 2 years
In GISSI 11324 men and woman with CHD use of 1 gr. of n-3 PUFA decreased CVD events including mortality 15%
Lancet
1989; 2;757-761, and 1999; 345:447-455.Slide14
Nuts, Soy, Phytosterols, Garlic
Nurses’ Health Study: five 1oz servings of nuts per week associated with 40% lower risk of CHD events
Metaanalysis of 38 trials of soy protein showed 47g intake lowered total, LDL-C, and trigs 9%, 13%, and 11%
Phytosterol-supplemented foods (e.g., stanol ester margarine) lowers LDL-C avg. 10%
Meta-analysis of garlic studies showed 9% total cholesterol reduction (1/2-1 clove daily for 6 months).Slide15
Controversy regarding efficacy of Soy ProteinSlide16
Lifestyle Heart Trial
41 male and female CHD patients
Randomized to <10% fat diet, exercise and meditation (Rx group) vs. Step 1 diet
At one year 37% LDL-C reduction, 22% weight loss, and 1.8 % regression in Rx group vs 2.3% progression in control group (quantitative coronary angiography)
At 5 years 20% LDL-C reduction, 3.1% regression in Rx group vs 11.8% progression in control group (n=35)
Ornish et al.
Lancet
1990; 336:129-133, and
JAMA
1998; 280:2001-2007.Slide17
Dietary Approaches: Zone/Soy Zone
Premise is to reduce insulin levels and stabilize glucose control by limiting starchy carbohydrates, emphasize low-density carbohydrates.
Emphasis on protein (avg. 75g/day for women and 100 g/day for men) (one-third of plate) (soy protein products for Soy Zone) and carbohydrates (primarily from vegetables, fruits to a lesser extent). Allows limited monounsaturated fats.
Metaanalysis of clinical trial on soy protein (avg. 47g/day) showed reduction in total cholesterol of 9%, LDL-C 13%, and triglycerides 11% (NEJM 1995; 333: 276-82)Slide18
Dietary Approaches: Atkins
Intended to correct unbalanced metabolism by restriction of carbohydrates to reduce insulin production and conversion of excess carbohydrates into stored body fat
Induction diet limits carbohydrate intake to 20 gms/day (e.g., 3 cups of salad veg or 2 cups salad + 2/3 cup cooked vegs) to induce ketosis/ lypolysis. Maintenance diet 25-30 gms/day.
Pure proteins, fats, and protein/fat allowed (all meats, fish, foul, eggs, cheese, veg oils, butter)
Most carbohydrates are not allowed--fruits, bread, grains, starchy vegs, or dairy products.Slide19
Data on Atkins and Zone diets
Medline analysis 2001
No large scale (>50 subjects) long term (>6months) follow-up studies could be identified with weight loss, cardiovascular risk assessment or clinical outcome data
Slide20
Pritikin Lifestyle Program
3-week residential program with exercise and ad libitum low fat (<10% of calories) plant based diet
4566 men and woman
Mean LDL-C reduction 25% in men and 20% in woman
Significant reductions in TG and HDL-C
Significant 3.2% reduction in body weight
Limited long-term follow up
Barnard et al.
Arch Intern Med
1991;151:1389-1394.Slide21Slide22
Very low fat
Ornish
(Reversal diet and Prevention diet)
Vegetarian with 10% calories from fat. No cooking oils, avocados, nuts, and seeds. High fiber. No caloric restriction.
Pritikin
Very low-fat (primarily vegetarian) diet based on whole grains, fruits, and vegetables
Intermediate
Sugar Busters
30% protein, 40% fat, 30% carbohydrates (low glycemic index)
Zone30% protein, 30% fat, 40% carbohydrates
Diet Evidence: Types of Treatment ProgramsSlide23
Very low carbohydrate
Atkins (Induction and Maintenance)
1
st
2 weeks (
<
20 grams of carbohydrates/day with no high glycemic foods).
Then can add 5 grams of carbohydrates/day each week to maximum of 90 grams of carbohydrates/day long term.
South Beach (3 Phases)
1st phase (2 weeks) significantly restricts carbohydrates2nd phase reintroduces low glycemic carbohydrates3rd
phase attempts to maintain weightCaloric restrictionWeight watchersAssigns foods a point value and restricts the number of points that can be consumed/day.
Diet Evidence:
Types of Treatment Programs (Continued
)Slide24
160 overweight and obese patients randomized to the Atkins, Zone, Weight Watchers, or
Ornish
diets for 1 year
Weight loss is similar among diet programs, but hard to sustain because of poor long-term compliance
Dansinger
, ML et al.
JAMA
2005;293:43-53
20/40*
26/40*
26/40*
21/40*
0
3
6
9
Atkins
Zone
Weight Watchers
Ornish
Wt loss (lbs)
*Ratio of individuals completing the study to those enrolled
Diet Evidence:
Primary PreventionSlide25
Lifestyle Heart Trial
41 male and female CHD patients
Randomized to <10% fat diet, exercise and meditation (Rx group) vs. Step 1 diet
At one year 37% LDL-C reduction, 22% weight loss, and 1.8 % regression in Rx group vs 2.3% progression in control group (quantitative coronary angiography)
At 5 years 20% LDL-C reduction, 3.1% regression in Rx group vs 11.8% progression in control group (n=35)
Ornish
et al.
Lancet
1990; 336:129-133, and JAMA 1998; 280:2001-2007.Slide26
Jenkins DJ et al.
JAMA
2003;290:502-10
0
10
20
30
-50
-40
-30
-20
-10
0
2
4
0
2
4
0
2
4
LDL-C
Change from Baseline (%)
LDL-C:HDL-C
CRP
Weeks
Weeks
Weeks
Low fat diet
Statin
Dietary portfolio*
*Enriched in plant sterols, soy protein, viscous fiber, and almonds
Diet Evidence:
Effect on Lipid Parameters and CRP
46
dyslipidemic
patients randomized to a low fat diet, a low fat diet and lovastatin (20 mg), or a dietary portfolio* for 4 weeks
A diversified diet improves lipid parameters and CRP levelsSlide27
Appel
LJ et al.
NEJM
1997;336:1117-24
Dietary Approaches to Stop Hypertension (DASH) Group
Diet Evidence:
Effect on Blood Pressure
A diversified diet improves blood pressure
459 hypertensive patients randomized to 1 of 3 diets for 8 weeks
Systolic blood pressure
(mm Hg)
Diastolic blood pressure
(mm Hg)Slide28
Diabetes Prevention Program (DPP)
Knowler WC et al.
NEJM
2002;346:393-403.
*Includes 7% weight loss and at least 150 minutes of physical activity per week
Placebo
Metformin
Lifestyle modification
Incidence of DM (%)
0
20
30
10
40
0
0
1
4
2
3
Years
Pre-diabetic Conditions:
Benefit of Lifestyle Modification
3,234 patients with elevated fasting and post-load glucose levels randomized to placebo, metformin (850 mg bid), or lifestyle modification* for 3 years
Lifestyle modification reduces the risk of developing DM Slide29
D
iabetes
P
revention
P
rogram:
Reduction in Diabetes IncidenceSlide30
Joshipura
KJ, et al.
2001
Ann Intern Med
134:1106-14
Nurses’ Health Study and Health Professional’s Follow-up Study
*Includes nonfatal MI and fatal coronary heart disease
CV=Cardiovascular, MI=Myocardial infarction
Diet Evidence:
Benefits of Fruits and Vegetables
126,399 persons followed for 8-14 years to assess the relationship between fruit and vegetable intake and adverse CV outcomes*
Increased
fruit and vegetable intake reduces CV riskSlide31
Pereira MA et al.
Arch
Int
Med
2004;164:370-76
RR=0.73, P<0.001
CV=Cardiovascular, CHD=Coronary heart disease
Diet Evidence:
Benefits of Whole Grains and Fiber
336,244 persons followed for 6-10 years to assess the relationship between dietary fiber intake and adverse CV outcomes
Increased dietary fiber intake reduces CV riskSlide32
Trichopoulou
A, et al.
NEJM
2003;348:2595-6
Variable
# of Deaths/ # of Participants
Fully Adjusted Hazard Ratio (95% CI)
Death from any cause
275/22,043
0.75 (0.64-0.87)
Death from CHD
54/22,043
0.67 (0.47-0.94)
Death from cancer
97/22,043
0.76 (0.59-0.98)
Diet Evidence:
Primary Prevention
22,043 adults evaluated for adherence to a Mediterranean diet, with points given for high consumption of vegetables, legumes, fruits, nuts, cereal, and fish and points subtracted for high consumption of meat, poultry, and dairy
High adherence to a Mediterranean diet is associated with a reduction in deathSlide33
Lyon Diet Heart Study
De
Lorgeril
M et al.
Circulation
1999;99:779-785
*High in polyunsaturated fat and fiber,
**High in saturated fat and low in fiber
Diet Evidence:
Secondary Prevention
605 patients following a MI randomized to a Mediterranean* or Western** diet for 4 years
A Mediterranean diet reduces cardiovascular eventsSlide34
Yokoyama M et al. Lancet. 2007;369:1090-8
Japan Eicosapentaenoic acid Lipid Intervention Study (JELIS)
*Composite of cardiac death, myocardial infarction, angina, PCI, or CABG
Years
w
-3 Fatty Acids Evidence:
Primary and Secondary Prevention
18,645 patients with hypercholesterolemia randomized to EPA (1800 mg) with a statin or a statin alone for 5 years
w
-3 fatty acids provide CV benefit, particularly in secondary prevention
CV=Cardiovascular, EPA=
Eicosapentaenoic acid Slide35
11,324 patients with a history of a MI randomized to
w
-3 polyunsaturated fatty acids [PUFA] (1 gram), vitamin E (300 mg), both or none for 3.5 years
GISSI Investigators.
Lancet
1999;354:447-455
w
-3 Fatty Acids Evidence:
Secondary Prevention
CV=Cardiovascular, MI=Myocardial infarction, NF=Non-fatal, PUFA=Polyunsaturated fatty acids
w
-3 fatty acids provide significant CV benefit after a MI
Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto miocardico (
GISSI-Prevenzione)Slide36
N-3 Fatty Acid Recommendation
American Dietetic Association 2007
For those without heart disease
Two 3.5 oz svgs/wk of fatty fish are assoc with 30-40% reduced risk of death from cardiac events.
Grade II FairSlide37
N-3 Fatty Acids
American Dietetic Association 2007
For those with heart disease
Approx 1g/d of DHA & EPA from fatty fish OR supplement decreases the risk of death from cardiac events.
Grade II FairSlide38
N-3 Fatty Acid Recommendation
American Dietetic Association 2007
Consume both marine & plant sources .
Fatty fish: two 3.5 oz serving/wk (salmon, herring, sardines)
or
1.5 g ALA/day eg 1 TBS canola, 1/2 TBS ground flax seeds.Slide39
2013 AHA/ACC Guideline on
Lifestyle Management to Reduce Cardiovascular Risk
Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Pharmacists Association, American Society for Nutrition, American Society for Preventive Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive Cardiovascular Nurses Association, and WomenHeart: The National Coalition for Women with Heart Disease
© American College of Cardiology Foundation and American Heart Association, Inc.Slide40
Charge of Lifestyle Work Group
Lifestyle Recommendations
Evidence Review on Diet and Physical Activity (in the absence of weight loss) to be integrated with the recommendations of the Blood Cholesterol and High Blood Pressure PanelsSlide41
Lifestyle Workgroup Critical Questions
CQ1
Among
adults*,
what is the effect of dietary patterns and/or macronutrient composition on CVD risk factors, when compared to no treatment or to other types of interventions?
CQ2
Among adults, what is the effect of dietary intake of sodium and potassium on CVD risk factors and outcomes, when compared
with
no treatment or
with
other types of interventions?
CQ3
Among adults, what is the effect of physical activity on blood pressure and lipids when compared
with
no treatment, or
with
other types of interventions?
*Those ≥18 years of age and <80 years of age.Slide42
Lifestyle Topics: Dietary Patterns
Mediterranean Diet
BP and lipids
DASH and DASH variations
BP and lipids,
and in subpopulations
High- vs. Low-Glycemic Diets
BP and lipidsSlide43
Mediterranean-Style Dietary Pattern Evidence Yield
3 RCTs
conducted in free-living populations and
1 prospective
cohort study that met criteria for inclusion on strategies for CVD risk factor reduction
using
the Mediterranean-style dietary
pattern.Slide44
Mediterranean-Style Dietary Pattern Description
There is no uniform definition of the Mediterranean-style dietary pattern diet in the randomized trials and cohort studies examined.
The most common features in these studies were diets that were:
high
in fruits (particularly fresh) and vegetables (emphasizing root and green varieties)
high in
whole grains (cereals, breads, rice, or pasta)
fatty fish (rich in omega–3 fatty acids) low
in red meat (and emphasizing lean meats); substituted lower-fat or fat-free dairy products for higher-fat dairy foodsSlide45
Mediterranean-Style Dietary Pattern Description (cont.)
used oils (olive or canola), nuts (walnuts, almonds, or hazelnuts), or margarines blended with rapeseed or flaxseed oils in lieu of butter and other fats
The Mediterranean-style dietary patterns examined tended to be:
moderate in total fat (32%–35% of total calories)
relatively low in saturated fat (9%–10% of total calories)
high in fiber (27–37g/day)
high in PUFA
particularly omega–3sSlide46
Mediterranean Diet and BP
Counseling
to eat a Mediterranean-style dietary pattern compared to minimal advice to consume a low-fat dietary pattern, in free-living middle-aged or older adults (with type 2
diabetes mellitus or
at least
3 CVD
risk
factors): BP
by 6–7/2–3 mm HgIn an observational study of healthy younger adults, adherence to a Mediterranean-style dietary pattern was associated with:
BP 2–3/1–2 mm Hg Strength of Evidence: LowSlide47
Mediterranean Diet and Lipids
Counseling
to eat a Mediterranean-style dietary pattern compared
with
minimal or no dietary advice, in free-living
middle-aged
or older adults (with or without CVD or at high risk for CVD) resulted in
no consistent effect on plasma LDL-C
, HDL-C, and TG; in part because of substantial
differences and limitations in the studies. Strength of
Evidence: LowSlide48
DASH: Dietary Approaches to Stop Hypertension
2 RCTs (6 citations) evaluating the DASH pattern met eligibility criteria.
DASH dietary pattern description:
high
in vegetables, fruits, and low-fat dairy products
high
in whole grains, poultry, fish, and nuts
low in
sweets, sugar-sweetened beverages, and red meatslow in saturated fat, total fat, and cholesterol
high in potassium, magnesium, calciumrich in protein and fiberSlide49
DASH and BP
When
all food was supplied to adults with
BP
120–159/80–95
mm Hg
and both body weight and sodium intake were kept stable, the DASH dietary pattern,
compared with a typical American diet of the 1990s:
BP 5–6/3 mm Hg
Strength of Evidence: High Slide50
DASH and Lipids
When
food was supplied to adults with a total cholesterol level <260
mg/dL and LDL-C level <160 mg/dL
and body weight was kept stable, the DASH dietary pattern,
compared with
a typical American diet of the
1990s: LDL-C by 11 mg/dL
HDL-C by 4 mg/dL • no effect on TG
Strength of Evidence: HighSlide51
DASH Subpopulations and BP
When all food was supplied to adults with BP 120–159/80–95 mm Hg and body weight was kept stable, the DASH dietary pattern, compared with the typical American diet of the 1990s,
BP in:
women and men
African-American and non–African-American adults
older and younger adults
hypertensive and nonhypertensive adults
Strength of Evidence: HighSlide52
DASH Subpopulations, BP, and Lipids
In patients who would benefit from
in BP and lipids, t
he DASH dietary pattern, when compared with the typical American diet of the 1990s,
BP and
LDL-C similarly in: women and menAfrican-Americans and non–African-American adults
older and younger adultshypertensive and nonhypertensive adults
Strength of Evidence: HighSlide53
DASH Subpopulations, Lipids
When
all food was supplied to adults with a total cholesterol level <260 mg/dL,
LDL-C level <160
mg/dL, and body weight was kept stable, the DASH dietary pattern, as compared to a typical American diet of the 1990s,
LDL-C and
HDL-C similarly in subgroups: African-American
and non–African-American adults, and hypertensive and nonhypertensive adults.
Strength of Evidence: Low Slide54
DASH Variations (OMNIHeart Trial)
1 RCT met eligibility criteria for DASH eating pattern variations
In OmniHeart, 2 variations of the DASH dietary pattern were compared to DASH:
1 which replaced 10% of total daily energy from carbohydrates with protein
the other which replaced the same amount of carbohydrates with unsaturated fat Slide55
DASH Variation Evidence
BP
In
adults with BP of
120–159/80–95 mm Hg
, modifying the DASH dietary pattern by replacing
10%
of calories from carbohydrates with
the same amount of either protein or unsaturated fat (8% MUFA and 2% PUFA) lowered systolic BP by 1 mm Hg
compared to the DASH dietary pattern. Among adults with BP 140–159/90–95 mm Hg, these replacements lowered systolic BP by 3 mm Hg relative to DASH.
Strength of Evidence: Moderate
Slide56
DASH Variation Evidence (cont.)
Lipids
In
adults with average baseline
LDL-C
130 mg/dL,
HDL-C
50 mg/dL, and TG 100 mg/dL, modifying the DASH dietary pattern by replacing 10% of calories from carbohydrates
with 10% of calories from protein
LDL-C by 3 mg/dL HDL-C by 1 mg/dL
TG by 16 mg/dL compared to the DASH
dietary patternSlide57
DASH Variation Evidence (cont.)
Replacing 10% of calories from
carbohydrates
with 10% of calories from unsaturated fat (8% MUFA and 2% PUFA)
LDL-C similarly
HDL-C by 1 mg/dL TG by 10 mg/dL compared to the DASH dietary pattern
Strength of Evidence: Moderate Slide58
Glycemic Index/Load Dietary Approaches
3 RCTs evaluating glycemic index met eligibility criteria.
There is insufficient evidence to determine whether low-glycemic diets vs. high-glycemic diets affect lipids or BP for adults without diabetes mellitus.
The evidence for this relationship in adults with diabetes mellitus was not reviewed.Slide59
Lifestyle Topics: Dietary Fat and Cholesterol
Saturated Fat - Lipids
Replacement of SFA with carbohydrates, MUFA, or PUFA - Lipids
Replacement of carbohydrates with MUFA or PUFA - Lipids
Replacement of
trans
fatty acids with carbohydrates, MUFA, or PUFA, SFA - Lipids
Dietary Cholesterol - LipidsSlide60
Dietary Fat and Cholesterol
3 trials evaluating saturated,
trans
fat, and dietary cholesterol.
In addition a search was conducted for meta-analyses and systematic reviews from 1990 to 2009.
4 systematic reviews and meta-analyses met inclusion criteria. Slide61
Saturated Fat
Food
supplied to adults in a dietary pattern that achieved a macronutrient composition of
5%–6%
saturated fat,
26%–27%
total fat,
15%–18% protein, and 55%–59% carbohydrates compared
to the control diet (14%–15% saturated fat, 34%–38% total fat, 13%–15%
protein, and 48%–51% carbohydrates): LDL-C 11–13 mg/dL in
2 studies
LDL-C 11% in another study.
Strength
of
Evidence
:
HighNote: Saturated fat was not an isolated change.Slide62
Saturated Fat (cont.)
In
controlled feeding trials among adults, for every
1%
of energy from
SF)
that is replaced by
1% of energy from carbohydrates, MUFA, or
PUFA:LDL-C is lowered by an estimated 1.2, 1.3, and 1.8 mg/dL, respectivelyHDL-C is lowered by an estimated 0.4, 1.2, and 0.2 mg/dL,
respectively For every 1% of energy from SFA that is replaced by 1%
of energy from: Carbohydrates and MUFATG
are raised by an estimated 1.9 and 0.2 mg/dL, respectively.PUFA
TG
are lowered by an estimated 0.4 mg/dL
.
Strength of
Evidence:
Moderate Slide63
Effect of Substitution of 1% Energy of Saturated Fat
Carbohydrates, MUFA
MUFA
PUFA
LDL-C (mg/dL)
1.2
1.3
1.8
HDL-C (mg/dL)
0.4
1.2
0.2
TG (mg/dL)
1.9
0.2
0.4Slide64
Substitution of Fatty Acids for Carbohydrates
In
controlled feeding trials among adults, for every
1%
of energy from
carbohydrates that
is replaced by
1% of energy from: MUFALDL-C
is lowered by 0.3 mg/dL, HDL-C is raised by 0.3 mg/dL, and TG are lowered by 1.7 mg/dL PUFA
LDL-C is lowered by 0.7 mg/dL, HDL-C is raised by 0.2 mg/dL, and TG are lowered by 2.3 mg/dL Strength
of Evidence: ModerateSlide65
Trans
Fat
In
controlled feeding trials among adults, for every
1%
of energy
from
trans MUFA replaced with 1% of
energy from: MUFA or PUFA LDL-C
by 1.5 and 2.0 mg/dL, respectively. SFA, MUFA, or PUFA HDL-C by 0.5, 0.4 and
0.5 mg/dL, respectively. MUFA
or PUFA TG by 1.2 and
1.3 mg/dL.
Strength of
Evidence
: ModerateSlide66
Trans
Fat (cont.)
In
controlled feeding trials among adults, the replacement of
1% energy
as
trans
MUFA with carbohydrates decreased LDL-C cholesterol levels by 1.5 mg/dL, and had no effect on
HDL-C cholesterol and TG levels.
Strength of Evidence: ModerateSlide67
Dietary Cholesterol
There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-C.Slide68
Lifestyle Topics: Sodium
BP:
Sodium Reduction - BP
Sodium Levels/ - BP and subpopulations
Sodium Reduction + DASH - BP
Sodium/ Other Minerals - BP
CVD Outcomes:
Sodium Reduction - CVD eventsSodium Intake - Stroke, CVD RiskSodium Intake - HFSlide69
Sodium and BP: Overall Results
In
adults aged 25–80 years with BP 120–159/80–95
mm Hg
, reducing sodium intake lowers BP.
Strength
of Evidence: HighSlide70
Different Levels of Sodium Intake
In
adults aged 25–75 years with BP 120–159/80–95
mm Hg, relative to approximately 3,300 mg/day
sodium
intake that achieved a mean 24-hour urinary sodium excretion of approximately 2,400
mg/day:
BP by 2/1 mm Hg Sodium intake that achieved a mean
24-hour urinary sodium excretion of approximately
1,500 mg/day
BP by 7/3 mm Hg
Strength
of
Evidence
:
ModerateSlide71
Different Levels of Sodium Intake (cont.)
In
adults aged 30–80 with or without hypertension, counseling
to
sodium
intake by an average of 1,150 mg per
day: BP
by 3–4/1–2 mm Hg Strength of
Evidence: ModerateSlide72
Sodium and BP in Subpopulations
In
adults with prehypertension or hypertension, reducing sodium intake lowers
BP in
women and men;
African-American
and
non–African-American adults; and older and younger adults.
Strength of Evidence: HighSlide73
Reducing
sodium intake lowers
BP in
adults with either prehypertension or hypertension when eating either the typical American diet or the DASH dietary pattern.
The
effect is greater in those with hypertension.
Strength of Evidence
: HighSodium and BP in
Subpopulations (cont.)Slide74
Sodium and Dietary Pattern Changes
In
adults aged 25–80 with
BP 120–159/80–95 mm Hg
, the combination of
sodium
intake + eating the DASH dietary pattern lowers BP more
than sodium intake alone. Strength
of Evidence: ModerateThere is insufficient evidence from RCTs to determine whether
sodium intake
+ changing dietary intake of any other single mineral (for example, increasing potassium, calcium, or magnesium)
BP more
than
sodium
intake alone. Slide75
Sodium and CHD/CVD Outcomes
A
in sodium intake of ~1,000 mg/day
CVD events by ~30%.
Strength
of Evidence
: LowHigher dietary sodium intake is associated with a greater risk of fatal and nonfatal stroke and CVD.
Strength of Evidence: Low Slide76
There
is insufficient evidence to determine
the association between
sodium intake and the development of
CHF.
There
is insufficient evidence to assess
the effect of
dietary sodium intake on CVD outcomes in patients with existing CHF.
Sodium and CHD/CVD Outcomes (cont.)Slide77
Lifestyle Topics: Potassium
Potassium intake – BP
Potassium intake – Stroke Risk
Potassium intake – CHD/ CHF/ CVD mortalitySlide78
Potassium and BP and CVD Outcomes
There
is insufficient evidence to determine
whether
dietary
potassium intake BP.
In observational studies with appropriate adjustments (BP, sodium intake, etc.), higher dietary potassium intake is associated with
stroke risk. Strength of Evidence
: LowSlide79
Potassium and BP and CVD
Outcomes (cont.)
There is insufficient evidence to determine whether there is an association between dietary potassium intake and CHD, CHF, and CVD mortality. Slide80
What’s New in Lifestyle?
Recommendations based on in-depth systematic reviews. P
revious reports used different methods and structure. More depth, less breadth.
More emphasis on dietary patterns
More data provided to support
saturated and
trans
fat restrictiondietary salt restrictionEvidence to support dietary cholesterol restriction in those who could benefit from
LDL-C is inadequate.Slide81
Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages, and red meats.
Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes).
Achieve this pattern by following plans such as the DASH dietary pattern, the U.S. Department
of
Agriculture (USDA) Food Pattern, or the AHA Diet.
LDL-C: Advise adults who would benefit from LDL-C lowering
*
to:
I
IIa
IIb
III
A
*Refer to 2013 Blood Cholesterol Guideline for guidance on who would benefit from LDL-C lowering.Slide82
Aim for a dietary pattern that achieves 5% to 6% of calories from saturated fat.
Reduce percent of calories from saturated fat.
Reduce percent of calories from
trans
fat.
LDL-C: Advise adults who would benefit from LDL-C lowering
*
to: (cont.)
I
IIa
IIb
III
A
I
IIa
IIb
III
A
*Refer to 2013 Blood Cholesterol Guideline for guidance on who would benefit from LDL-C lowering.
I
IIa
IIb
III
ASlide83
BP: Advise adults who would benefit from BP lowering to:
Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened
beverages,
and red meats.
Adapt this dietary pattern to appropriate calorie requirements, personal and cultural food preferences, and nutrition therapy for other medical conditions (including diabetes mellitus).
Achieve this pattern by following plans such as the DASH dietary pattern, the U.S. Department of Agriculture (USDA) Food Pattern, or the AHA Diet
.
I
IIa
IIb
III
ASlide84
Lower sodium intake.
Consume no more than 2,400 mg of
sodium/day;
Further reduction of sodium intake to 1,500
mg/day
can result in even greater reduction in BP; and
Even without achieving these goals, reducing sodium intake by at least 1,000
mg/day
lowers BP
.BP: Advise adults who would benefit from BP lowering to: (cont.)
I
IIa
IIb
III
A
I
IIa
IIb
III
BSlide85
Combine
the DASH dietary pattern with lower sodium intake.
BP: Advise adults who would benefit from BP lowering to: (cont.)
I
IIa
IIb
III
A